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Report on Priorities for Implementation of
New Hampshire's 10-year Mental Health Plan of 2019
Pursuant to Chapter 248, Laws of 2019, (Senate Bill 292) to the New Hampshire Health and
Human Services Oversight Committee, et al.
Division for Behavioral Health
New Hampshire Department of Health and Human Services
September 2021
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence.
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INTRODUCTION
The NH 10-year mental health plan (hereinafter “10-year mental health plan”) set the vision
for NH’s mental health system: New Hampshire’s mental health system will be robust and
cohesive; will respect the dignity and centrality of the whole person; empower people, family, and
community; and will reduce stigma while facilitating rapid access to a coordinated, high quality
array of localized services and supports for all, through a centralized access point.
Together, the shared wisdom of individuals with lived experience and their families,
providers, government representatives, and the public created the 10-year mental health plan that
includes short and long-term recommendations to effect high-level system change. These
stakeholders have been critical to implementing the fourteen (14) foundational recommendations.
In accordance with Chapter 248, Laws of 2019 (SB 292), the New Hampshire Department of
Health and Human Services, Division for Behavioral Health (hereinafter “Department”) is pleased
to submit this report relative to the implementation of New Hampshire’s comprehensive 10-year
mental health plan.
Specifically, and as related to the current report, SB 292 requires the Commissioner to
submit a report containing the priorities for implementation of the 10-year mental health plan
annually, beginning on or before September 1, 2020, relative to the status of fully implementing
the 10-year mental health plan.
By way of background, the 10-year mental health plan, published in January 2019, sets a
vision for the State’s mental health system and prioritizes 14 recommendations to implement
within its first two years. These recommendations are foundational and intended to strengthen the
system’s infrastructure. Following implementation of these recommendations, New Hampshire
will be poised to successfully expand and sustain a robust mental health system.
To address the priority recommendations, the Department began preparatory steps for those
areas subject to the finalization of state fiscal years (SFYs) 2020-2021 budget while
implementation began for those areas that were not dependent upon the enactment of the pending
budget. The Continuing Resolution and delay in approval of the SFY 20/21 budget had an impact
on the timeline for the initial development and implementation of recommendations outlined in
the 10-year mental health plan because it slowed creating the DHHS capacity needed to support
the program, policy, finance and contracting work connected to the budget. Additionally, the
COVID-19 pandemic and its impact across the entire state, including the Division for Behavioral
Health, and provider organizations including community mental health centers, peer support
agencies, residential and community based providers, has slowed expected progress on the 10-year
mental health plan.
Since the fall of 2020, as the pandemic has changed, there has been a renewed focus on the
infrastructure and system recommendations outlined in the 10-year mental health plan. This report
will reflect progress made to date on each of the 14 recommendations.
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Summary of Activities, Priorities and Progress Toward Implementation of the 10-Year
Mental Health Plan
Recommendation #1: Medicaid Rate Increase for Mental Health Services:
In SFY2019, the Department temporarily increased by $6M in total funds Medicaid rates
for providers of mental health services. The funding is included in the biennial budget and the SFY
20/21 biennial budget passed by the Legislature included significant increases to Medicaid rates
for behavioral health providers. The first 3.1% increase for mental health rates went into effect on
January 2020 and a second 3.1% increase went into effect on January 2021.
The Department also received authorization from the U.S. Centers for Medicare and
Medicaid Services (CMS) to pay interim enhanced rates to eligible Community Mental Health
Programs (CMHP) for select adult services to improve access and coordination. Up to $5M
in directed payments were invested each state fiscal year effective from 7/1/2018 through
6/30/2021.
In state fiscal year 2021 directed payments included:
$3M – Assertive Community Treatment (ACT) Services – payments to improve access and
support ACT program fidelity.
$1.2M – New Hampshire Hospital (NHH) and Designated Receiving Facility (DRF)
Discharges and follow-up services – payments for a face-to-face service the same-
day/next-day of discharge from NHH or a DRF to enhance care coordination for transitions
and for any subsequent weekly face-to-face services, up to 180 days, to improve follow-up
care and decrease readmission rates.
$200K – Specialty Residential Services – to support specialized services for individuals
who have co-occurring mental health and developmental disabilities.
$600K – Mobile Crisis Teams – to support face-to-face crisis response services provided
by mobile crisis teams.
The Department has submitted an application to CMS to extend these directed payments
through SFY 2022. Changes to the directed payment application include a reduction of the
allocation to ACT due to inability to meet service targets and removal of mobile crisis team
payments due to the statewide expansion of mobile crisis as a part of the crisis system
transformation efforts. New directed payments were added including a directed payment for timely
prescriber services to ensure prescriber appointments within 21 days of a new intake appointment
and a directed payment for the delivery of evidence-based Illness Management and Recovery
(IMR) services. The goal of this expansion is to increase access to illness management and
recovery services that enable people to more successfully remain in the community.
In order to support the expansion of Transitional Housing Programs (THP), the
Department conducted a financial analysis and transferred funds in SFY 2021 to the Medicaid
budget to create a standard per diem rate for all THPs. The current fee schedule now includes a
THP per diem rate of $232.79.
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In an effort to increase the capacity of mental health community residences, the Department
approved vendors to bill at the same (THP) per diem rate effective July 1, 2021. All community
residences that certify under He-M 1002 are now eligible to bill at the $232.79 per diem rate.
As a part of the behavioral health crisis system transformation, the Department evaluated
Medicaid billing practices for crisis services, inclusive of mobile crisis response. The analysis
resulted in the creation of five Medicaid crisis billing codes that are uniquely structured and priced
to support the delivery of sustainable crisis services. The new rates and provider billing guidance
went into effect July 1, 2021
Recommendation #2: Address Emergency Department Waits:
On June 7, 2021 – for the first time since the COVID-19 pandemic began – there were no
adults in hospital emergency departments waiting for inpatient psychiatric treatment. This was due
to significant steps taken to date by the Governor, legislature, Department, providers, and
advocates to find and implement solutions.
On May 13, 2021 Governor Chris Sununu issued an Executive Order that allowed the
Department to take immediate steps to ensure that New Hampshire residents experiencing a mental
health crisis receive timely and appropriate medical care. The Department has worked to
implement short-term solutions to the emergency department wait list, including offering long-
term care facilities a $45,000 per bed incentive to accept geropsychiatric patients from New
Hampshire Hospital or the Glencliff Home and creating an additional 25 beds at New Hampshire
Hospital. Other ongoing efforts include:
I. Short term measures
Comprehensive Crisis Services: Senate Bills 11 and 14 included provisions and funds to
expand crisis services such as Mobile Crisis Response Teams (MCRT) for both adults and
children. The Request for Proposal as required by SB 11 for an additional MCRT was posted but
the procurement was canceled. SB 14 required the development of statewide MCRT for children
and youth. The Department has worked diligently with stakeholders to evaluate opportunities to
achieve efficiencies and improve access to crisis services by exploring models that would offer
fully integrated crisis services for all populations (children, youth, adults, mental health, and
substance use). The Department posted a Request for Information in October 2019 to solicit input
about proven crisis response models that are statewide, integrated, and financially sustainable.
More than a dozen responses from stakeholders both in-state and nationally were submitted. It is
clear from the responses and from experience, that a fully integrated model that serves adults,
children and youth experiencing a mental health and/or substance use crisis is most efficient in
terms of provider capacity and financial feasibility and sustainability.
A model for integrated crisis services has been selected and aligns with the national best
practices of Crisis Now (the national model for crisis system improvement) and 9-8-8 (the
forthcoming national three-digit number for all behavioral health crises). NH’s behavioral health
crisis response model, the NH Rapid Response, is in the early implementation phase and contracts
have been awarded. The Rapid Response model will require system transformation. The below
graphic illustrates the current and future state of crisis services in NH. The model has three parts:
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First is the centralized, 24/7 statewide access point where all behavioral health crisis
calls/texts/chats with be answered, triaged, and, in many cases, de-escalated altogether. The access
point is contracted to Beacon Health Options. Second, if the access point cannot de-escalate the
situation, a mobile Rapid Response team will be deployed. The mobile Rapid Response teams will
be staffed by all 10 Community Mental Health Centers (CMHCs) and teams will be available to
deploy to the location of the person in crisis. Options for same day in-office appointments and
telehealth visits will also be offered to callers. Third, once stabilized, all individuals who engage
with the Rapid Response system will have access to short-term stabilization services through the
CMHCs.
Planning and implementation efforts for this transformation are currently underway. The
NH Rapid Response system is expected to be fully operational by January 1, 2022 with the access
point, mobile teams, and location based services available. Implementation of mobile services may
vary in some regions due to challenges with workforce recruitment. However, the system is
designed to be statewide; the closest available team will deploy. In addition to the existent mobile
crisis teams in Concord, Manchester, and Nashua, some regions have already begun staffing-up
their mobile Rapid Response teams and are starting to deploy on a limited basis. These efforts by
CMHCs to pilot their mobile deployments prior to January 1, 2022 will enable them to fine tune
operations in preparation for more widespread deployment.
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The goal of the Rapid Response system is to provide easy access to behavioral health care
for children, youth, adults, and families in crisis. The system is intended to ensure individuals
receive the clinically appropriate level of care in the modality and environment of their choice
(phone, text, chat, community, office, telehealth). A core outcome of this system will be to engage
people early, provide them with access to behavioral health services, and divert them from entering
emergency departments unnecessarily. The below graphic illustrates the projected number of
encounters expected statewide. As depicted, approximately 80% of individuals who reach out to
the access point will not require a higher level of intervention.
The Department submitted a grant application and was awarded temporary funding due to
COVID-19 from the Substance Abuse and Mental Health Services Administration (SAMHSA) to
expand crisis response services for children, youth, and adults. The $4.8M SAMHSA Rapid
Response grant award expanded crisis response teams at all 10 community mental health centers
by providing one additional Masters level clinical specialist and one additional peer support
specialist per region. This grant has focused on expanding the availability of behavioral health
crisis services for individuals, targeting uninsured individuals and first responders, affected by the
COVID-19 pandemic. This work continues with grant funds through May 2022 and will ultimately
be integrated into the long-term vision Rapid Response teams explained above.
Rates for community-based Designated Receiving Facilities (DRF): Senate Bill 11
provided for an increase to DRF rates, for the establishment of an atypical rate for voluntary
inpatient psychiatric admissions, and for funds to renovate existing hospital facilities to expanded
DRF capacity statewide. In accordance with House Bill 1, eight (8) new DRF beds were
established in 2019 through contract with the Department. Additionally, 16 new youth beds were
established in 2020 and 10 new youth beds were established in 2021.
Training, education, and collaborative efforts: NH Hospital’s Chief Medical Officer and
Lead Attorney provided trainings for emergency department and community mental health center
staff as part of their collaborative work with the NH Hospital Association. Staff were trained in
Involuntary Emergency Admissions (IEA) in order to learn the laws that govern IEAs and who is
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appropriate to certify for an IEA. The training also included a statutory overview of conditional
discharges and conditional discharge revocations. These trainings have paused but the Department
is working with the hospital association and community behavioral health association to identify
alternative opportunities to train behavioral health staff in community hospitals.
The Foundation for Healthy Communities’ Behavioral Health Clinical Learning
Collaborative is a two-year program designed to address the management and treatment of patients
experiencing mental health crises in the emergency department (ED) setting, and is funded by the
Endowment for Health, New Hampshire Charitable Foundation and Foundation for Healthy
Communities’ Partnership for Patients. The Collaborative members consist primarily of New
Hampshire emergency department and community mental health center staff. The Collaborative is
working to develop and adopt best practices to ensure the immediate evaluation and delivery of
services to patients with behavioral health emergencies waiting in the ED in order to support
patient stabilization and treatment in the most appropriate setting.
Efforts are underway through expansive cross-sector partnerships to expand event
notification processes, procedures and technology to support care coordination for patients
experiencing a behavioral health crisis. Integrated event notification systems will ensure that
insurance companies, including Managed Care Organizations, emergency departments, NH
Hospital and other designated receiving facilities, and community mental health centers all receive
notification(s) when a patient is in the emergency department. This infrastructure will facilitate
more rapid identification, assessment, and intervention for individuals in emergency departments
experiencing a behavioral health crisis.
DHHS should file a new Section 1115 waiver: The Department has submitted an
application to CMS to amend NH’s Substance Use Disorder Treatment and Recovery Access
Section 1115(a) Research and Demonstration Waiver. The proposed amendment is part of the
Department’s approach to address the ongoing challenge of psychiatric Emergency Department
(ED) boarding and to support the comprehensive, integrated continuum of mental health treatment
and care available in the state. The proposed amendment requests authority for Medicaid
reimbursement for short-term medically necessary residential and inpatient treatment services
within settings that qualify as institutions for mental disease (IMDs). The State’s goal is to increase
access to treatment options for Medicaid eligible adults ages 21-64 with Serious Mental Illness
(SMI) to appropriately address acute mental health needs, decrease rates of morbidity and
mortality for covered populations, and decrease utilization of less appropriate services, such as
EDs. A public hearing was held on 8/9/21 and public input was accepted through a 30-day public
comment period. The application was submitted on September 3, 2021 with a requested effective
date for the amendment of July 1, 2022.
Expansion of Transitional Housing Programs: Funding was provided in the SFY 20-21
State budget to construct forty (40) new transitional housing beds specifically designated to serve
forensic patients, those with complex behavioral health conditions, or those transitioning from
NHH. The Department submitted a letter to the Fiscal Committee for the General Court, pursuant
to Chapter 346, Section 221 (Laws of 2019) outlining the plan for these beds. The June 26, 2020
letter described the Department’s plan to develop a 16-bed community residence at the Philbrook
Center and procure for additional transitional housing programs.
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Philbrook Adult Transitional Housing (PATH) accepted its first client on September 14,
2020. This 16-bed transitional housing program, located at the corner of South Fruit and Clinton
Streets in Concord, is owned, operated, and staffed by the Department. PATH has served 58 clients
as of August 25, 2021, 81% of whom were on conditional discharges from New Hampshire
Hospital. Fifty-seven of the referrals came from New Hampshire Hospital with one from the
Residential Treatment Unit at the NH Department of Corrections. Average length of stay for those
discharged from PATH is 64 days (range of 1 day to 224 days). Of discharged clients, 35 went to
live in apartments and 9 returned to NH Hospital.
A Request for Application for the remaining transitional housing beds was posted and
resulted in contracts for an additional 5 beds.
II. Reallocation of Capacity at New Hampshire Hospital (NHH)
The Department, working with the Governor and Legislature successfully transitioned the
children’s unit from NHH to Hampstead Hospital in SFY21, expanding its scope of acute
psychiatric treatment services for children on both a voluntary and involuntary basis. This move
is ensuring access to a specialized treatment setting designed to meet the unique needs of children
and youth experiencing mental illness. Hampstead Hospital worked closely with the Department
to update policies and procedures to ensure compliance with DRF designation and contractual
requirements.
This transition of care enabled NHH to increase adult capacity by converting the existing
child and youth beds to adult beds. When child services transitioned to Hampstead, NHH added
staff positions and 48 adult beds. NHH continues to operate at capacity up to 187 adults. NHH
continues to monitor the contract for child inpatient psychiatric services at Hampstead Hospital.
Currently Hampstead Hospital serves as the only inpatient psychiatric provider for children in NH
and continues to have DRF status.
Recommendation #3 Renewed and Intensified Efforts to Address Suicide Prevention:
SB 282 is now RSA 193-J requiring schools to have a suicide prevention plan and training
as of July 2020. The NH Department of Education put out a technical advisory:
https://www.education.nh.gov/sites/g/files/ehbemt326/files/inline-documents/suicide-
prevention.pdf and has posted a series of videos for schools to review describing the new
requirement and the programs available statewide that would help schools meet this requirement.
Many districts around the state are well underway in ensuring that they have plans and training
available for all of their staff. The Department of Education funded a contract with NAMI NH to
host a Connect train the trainer event. This will provide eight (8) trainers to conduct
virtual Connect Trainings across the state through 9/29/21.
The approved State budget for the last four years (SFY2020-2023) included $200,000 in
each State fiscal year to support NH’s suicide prevention hotline and $250,000 in each fiscal year
to support suicide prevention efforts, including training.
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The additional funding provided to New Hampshire’s accredited state suicide prevention
lifeline, Headrest, has already made an impact on the rate of calls answered in state. Headrest has
experienced an increase in both in-state call answer rates and outgoing follow-up calls. The
Department has also entered into contract with Beacon Health Options that will pursue
accreditation as a national suicide prevention lifeline. This will expand NH’s Lifeline network
capacity and increase in-state answer rates for calls, texts, and chat messages.
In SFY2020, the Suicide Prevention Council (SPC) submitted a written request to the
Department to use part of the allocated $250,000 to fund a fulltime staff position to serve as a
statewide suicide prevention specialist. In making this request, they noted that the Suicide
Prevention Resource Center, which is the national technical assistance provider on suicide
prevention for SAMHSA, recently released a white paper on Recommendations for State Suicide
Prevention Infrastructure. The recommendations called for states to designate a lead division or
organization, identify and secure resources, maintain a suicide prevention plan, and maintain a
dedicated leadership position.
The Department designated the Division for Behavioral Health as the lead organization to
prioritize suicide prevention and provide administrative support and ensure continuity of suicide
prevention efforts and hired its first Suicide Prevention Coordinator in March 2021. This position
will lead the Department’s suicide prevention activities both internally and externally as well as
coordinate the NH Suicide Prevention Council (SPC). This position works with many partners
across the state to address suicide prevention, incorporating new programs and strategies,
recommendations of the 10-year mental health plan, and emerging best practices to decrease
suicide attempts and fatalities across New Hampshire.
The SPC revised the State Suicide Prevention Plan in 2021. SPC’s Suicide Prevention Plan
is comprehensive and data-driven. Additionally, it is aligned with the National Action Alliance
priority areas, best practices developed the Suicide Prevention Resource Center, supports the Zero
Suicide framework, and helps fulfill the NH 10-year mental health plan. The SPC’s overarching
goals, which are consistent with the previous plan, are to promote awareness that suicide in New
Hampshire is a public health problem that is generally preventable and reduce the stigma
associated with obtaining mental health, substance misuse, and suicide prevention services.
New Hampshire received a planning grant from Vibrant Emotional Health to assist in
preparing for the transition of the 10-digit Suicide Prevention Lifeline to 9-8-8, a simple, easy-to-
remember, 3-digit dialing code for all behavioral health related crises. In order to plan for the
changes needed to successfully implement this by July 2022, New Hampshire has created a
planning coalition of key stakeholders that are essential to 9-8-8 roll out. The coalition meets
monthly and includes staff from the Department including the new Suicide Prevention
Coordinator, other Suicide Prevention partners like NAMI NH and American Foundation for
Suicide Prevention, individuals with lived experience of suicidal thoughts and attempts, Law
Enforcement, Fire and EMS providers, the State’s current Lifeline provider, Headrest, and
representatives from the State’s Community Mental Health Centers, Beacon Health Options,
Doorways system and 211. The planning grant also allows for NH to take part in a national
community of practice to learn more about best-practices across the country.
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DHHS and the SPC launched I Care NH in May 2021. I Care NH is a mental health
and wellness initiative of the New Hampshire Department of Health and Human
Services and the NH Suicide Prevention Council. The I Care NH message was
developed by utilizing the National Strategy for Suicide Prevention and the Framework
for Successful Suicide Prevention Messaging that promotes hope, connectedness,
social support, resilience, treatment and recovery. The I Care NH message can reach a general
population to encourage talking and help seeking long before a crisis and can also reach vulnerable
individuals to fundamentally change the course for those who are struggling with their mental
health, substance use or thoughts of suicide. The I Care NH website was launched in April 2021
and had 1,298 visits by August 2021. DHHS worked with the NH Association of Broadcasters to
create short public service announcements to be played on the radio. The radio spots began in May
and were aired 961 times in May and June. On Social Media, through DHHS Facebook and
Twitter, I Care NH posts have reached over 14,600 people with over 140 engagements. These
efforts are ongoing. Most recently, DHHS added additional funding to Regional Public Health
Network contracts to aid in the regional dissemination of this messaging in partnership with
ongoing work of the substance misuse prevention coordinators and local coalitions.
The Department entered into a training contract in SFY 2020 to launch its training of
Question, Persuade, Refer (QPR) to its employees. QPR is an evidence-based prevention program
that teaches participants how to recognize the warning signs of a suicide crisis and how to question,
persuade, and refer someone to help. Today, 20 DHHS employees have been trained as QPR
trainers and have trained over 300 staff members from across the Department.
Since 2017, NH has hosted 23 Counseling on Access to Lethal Means (CALM) trainings
that reached more than 384 people statewide. CALM is a suicide prevention skills training course
that focuses on how to assess whether a person at risk for suicide has access to firearms or other
lethal means and how to work with them and their family to limit access until they are no longer
at an elevated risk.
The Behavioral Health Clinical Learning Collaborative is an effective example of NH
healthcare organizations coming together to create a trusted, cohesive forum to address the clinical
aspects of the behavioral health boarding crisis in New Hampshire emergency departments. The
Collaborative members consist of representatives from acute care hospitals, psychiatric hospitals,
community mental health centers, along with interested stakeholders.
The Collaborative has developed the Suicide Screening & Intervention Toolkit to
standardize screening and assessment for suicide in all New Hampshire Emergency Departments.
Most hospitals in NH have joined the community mental health centers in adopting the Columbia-
Suicide Severity Rating Scale (C-SSRS) as their screening tool for suicidal ideation. The
Collaborative members designed the Suicide Screening & Intervention Toolkit to create a
standardized, local approach to using the C-SSRS in hospital EDs. The goal is to help staff build
the confidence necessary to identify, support, and treat patients with suicidal ideation.
NH’s Medicaid Managed Care Organizations (MCO) have made great strides to
implement the evidence-based Zero Suicide framework. MCOs have integrated Zero Suicide sub
committees within their agencies, engaged in the Zero Suicide Institute, and partnered to bring a
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Zero Suicide training as well as trauma informed care panel to the first ever NH MCO Training
symposium. The MCOs continue to work as a driving force in system change to increase awareness
about suicide prevention and provide training for staff at all levels of the healthcare system in order
to identify, engage, and treat individuals at risk, transition them through levels of care with warm
hand-offs, and improve policies, procedures, and health outcomes. Each MCO ensures training is
provided to their clinical staff to enhance the clinical practices of those who work in direct contact
with members.
New Hampshire was the recipient of three previous Garrett Lee Smith Grants, with NAMI
NH as the state’s designated applicant, in 2005, 2009, and 2013. These three-year grants provided
stakeholders throughout New Hampshire with opportunities to improve outcomes for youth and
young adults at risk of suicide.
The Garret Lee Smith New Hampshire Nexus Project 2.0 (GLS NHNP 2.0) was awarded
in January 2020 to NAMI NH and is a cross-systems, collaborative approach to reduce suicide
incidents among youth and young adults ages 10-24 and continues with implementation across
systems. This grant will continue to strengthen and enhance existing systems to recognize and
connect with at-risk youth and young adults and develop referral pathways and cohesive
procedures to connect them with services and resources.
Recommendation #4 Enhanced Regional Delivery of Mental Health Services
The Department is working to implement a mental health portal, which would provide an
integrated point of entry for local and regional information for mental health, substance use and
other services. The Department entered into a contract with Beacon Health Options on June 30,
2021 to establish and operate a centralized access and crisis call center via a single, statewide
telephone number for individuals experiencing and mental health and/or substance use disorder
crisis. This contract requires capabilities to facilitate referrals for ongoing treatment and services
to meet social determinants of health needs. This access point will partner with and establish
memorandums of understanding with NH’s 211 providers, the Doorways, CMHCs, and NH’s
accredited suicide prevention hotline, Headrest. Together, this system creates a no wrong door
approach wherein NH citizens can easily access behavioral health care for crisis and ongoing
needs.
As referenced above, the work taking place to roll-out 9-8-8 and NH’s Rapid Response
crisis system perfectly complements and align with this recommendation to enhance regional
delivery via a centralized access point.
SB 14 required statewide mobile crisis response for children; expansion of community
based services for children; consolidated parent information; and an evidence-based practice
clearinghouse. These components could connect to a regional entity for behavioral health access
and information. The Department has developed a work plan and timeline to address these
recommendations and is taking a system-wide approach that would ideally expand and integrate
these efforts to be available for both children, youth, and adults affected by mental illness and/or
substance use. The development of an integrated online treatment locator and clearinghouse is
important to youth, adults, families, and caregivers to ensure they are informed about where and
how to access care. This work is integrated into the larger DHHS work to establish a fully
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integrated solution for closed loop referral and provider locator. This integrated approach will
ensure a more robust approach and not create further silos for families who may have needs that
are more holistic.
The evidence based practice (EBP) technical assistance and training and First Episode
Psychosis training work was developed as an RFP with the goal of centralizing EBP training and
technical assistance; the resulting contract is in process.
Recommendation #5 Community Services and Housing Supports
SB 11 appropriated funds for the purpose of contracting with programs that enable
individuals with serious mental illness to attain and maintain integrated, affordable, supported
housing. Following recommendations outlined in the 10-year mental health plan, the Department
released a comprehensive community-housing request for proposal (RFP) inclusive of a variety of
housing models. The procurement closed on 12/29/2020 and resulted in a single contract to
develop 3 supported housing placements for individuals with severe mental illness who may have
co-occurring disorders.
The Department included language in contracts with all 10 CMHCs to stand up a minimum
of 6 new supported housing beds in their region including, but not limited to, transitional or
community residential beds by December 31, 2021. The CMCHs have submitted plans and budgets
for Department review that include the type of supported housing beds proposed, staffing plans,
anticipated location, and implementation timeline.
NH’s Housing Bridge Subsidy program was budgeted for 398 vouchers since state fiscal
year 2018. HB 1 included funds to expand the Housing Bridge Subsidy program and transitional
housing for adults and youth. The Department amended contracts to expand the Housing Bridge
Subsidy program by adding funds and staff to support up to 500 housing bridge vouchers. The
contract amendment, effective in state fiscal year 2021, also included funds and scope to develop
a pilot program for individuals with mental illness transitioning out of the criminal justice system
in need of housing support services. The program, Integrative Housing Voucher Program, focuses
on individuals who have a criminal background that would otherwise prevent them from entering
the Housing Bridge Subsidy program due to time constraints related to HUD rules. Integrative is
a temporary supportive housing program that provides a housing voucher coupled with a
designated housing specialist who will work with the individual to ensure they remain safely
housed. The housing specialist also works closely with the individual’s treatment team at the
community mental health program, in an effort to create a true network of wrap around supports.
Individuals entering the Integrative program may be coming out of the New Hampshire prison
system, a local New Hampshire jail, or may be homeless. The program operates similar to the
Housing Bridge Subsidy program, but the length of stay may be longer in Integrative in order to
qualify for HUD.
The Department has a partnership with the New Hampshire Housing Finance Authority for
the HUD grant-funded PRA811 Program. This program is based on a permanent housing voucher
that remains with the rental property. Once a unit is secure, the voucher remains with the unit even
if an individual chooses to relocate. An individual in the PRA811 program must pay 30% of their
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income toward rent, calculated by the property management company. Since June 2017, the State’s
Section 811 Project Rental Assistance program has placed 132 individuals with severe mental
illness in permanent housing. Fourteen (14) additional units are currently open with applicants in
the process to move in.
SB 14 required the expansion of the FAST (Families and Systems Together) Forward
program and Care Coordination services provided beyond the FAST Forward program by the Care
Management Entity (CME). The CME expansion includes 1. Increasing FAST Forward to serve
children and youth in their home and community as well as children and youth served by DCYF
and 2. Expand oversight of youth in both residential treatment and psychiatric hospitals to ensure
children are not in these settings longer than clinically necessary, and to facilitate a smooth and
successful transition of the child/youth back to home and community.
Throughout this reporting period, FAST Forward has continued to expand the provision of
services. Since the beginning of calendar year 2019, the CME and FAST Forward program
continue to experience significant growth and expansion, going from 100 enrolled youth in
February 2019 to 408 in July 2021. In addition to the expansion of FAST Forward, a new service
called Transitional Residential Enhanced Coordination (TRECC) was added. TRECC is developed
to help support youth and their families, collaborate with key stakeholders and treatment team
members, in order to facilitate successful transitions to and from residential treatment.
Governor and Executive Council approved an amended contract with the current CME in
June 2020. The contract for a second CME was developed and approved in June of 2020.
Establishing levels of care for youth residential treatment programs is critical work that has been
underway since fall of 2019. The Bureau for Children’s Behavioral health renewed levels of care
to establish 5 distinct levels of care for youth residential programs. Level 1 is the least intensive,
more community based and supportive living option for youth and transitional aged young adults.
Level 5 is the most intensive clinical level of care, an accredited Psychiatric Residential Treatment
Facility (PRTF). Each level of care will have models of care for trauma, evidenced based practices
for clinical care, and models for reduction of use of restraints and seclusion, among others.
Contracts for the new Residential Treatment System have been completed and all but 1
was approved by Governor and Executive Council at the time of the writing of this report, and are
in the process of implementation. The last contract is expected to be submitted to Governor and
Council for approval in the coming weeks. The new contracts encompass all new requirements
relative to the new levels of care, which includes the implementation of a trauma model, new
staffing ratios, new requirements of clinical staffing and ratios, including access to nursing, and
becoming accredited by a national accrediting body. The Department also has a contract in place
with Maximus, a national provider, who will be assessing each child who may be in need of
residential treatment, to determine what level of care, if any, best meets the child’s clinical needs.
Recommendation #6 Step-up/Step-down Options
In accordance with the 10-year mental health plan and funds appropriated in HB 1 in
the State’s 2020/2021 budget, New Hampshire has identified a need to expand programs that
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support people at risk of hospitalization, safely and therapeutically in their communities, while
reducing avoidable psychiatric hospitalization and readmission.
In December of 2020, New Hampshire entered into contract with four (4) Peer Support
Agencies located in Monadnock, Nashua, Manchester and the Seacoast, each to operate 3-bed
Recovery-Oriented Step Up/Step Down programs. These programs offer a new level of crisis care
in NH. Step-Up/Step-Down Programs provide short-term recovery based transition services for
adults (18 years or older) who require more intensive support to reduce the need for admission to
an inpatient setting (step-up) or who are transitioning from inpatient or institutional settings into
the community (step-down). These programs provide non-clinical peer supports with access to
peer staff 24 hours a day, 7 days per week. Stays are limited to ninety (90) days per episode of
need. Staff focus on recovery oriented peer support services that also work to coordinate and
engage with outpatient community based clinical treatment providers. Programs are operated in
accordance with the SAMHSA Core Competencies for Peer Support Workers in the behavioral
health system and accept referrals from a multitude of community based treatment providers.
SB 14 and the federal Families First Prevention Services Act provide opportunities to look
critically at how NH uses residential treatment for children and youth. As described above, the
State is making progress to implement the plan for transforming the residential treatment system
to meet the needs of all children more effectively. This includes reviewing cases of children and
youth currently in treatment either in or out of state; developing a level of care system framework
with clear descriptions and inclusion/exclusion criteria; selecting a single standardized assessment
tool for use across all children’s behavioral health providers; and cross-walking eligibility criteria
with levels of care and the chosen assessment tool. Resources to address these requirements were
incorporated into HB 1.
Recommendation #7 Integration of Peers and Natural Supports
In collaboration with peer support agencies, community mental health programs and
providers, and hospitals, the Department is evaluating training needs, increasing the pool of state
trainers, focusing on core training requirements, and exploring opportunities to leverage funding
and cross-train peers in various parts of the system.
In support of Recommendation #7, the Department has, to date:
State Fiscal Year 2020:
1. Increased positions and training opportunities for peer and community health worker as
part of the ProHealth NH grant awarded to the Department for integration of behavioral
health and primary care by Substance Abuse and Mental Health Services Administration
(SAMHSA).
2. Included language in all newly developed contracts starting in SFY 2020 for Transitional
Housing Programs (THP) that direct care personnel should include a minimum of one (1),
part time peer support specialist as defined in He-M 426.13 (d)(4) during daytime
programming hours.
3. Integrated peers as core members of crisis response teams at each of the ten community
mental health centers as described above as part of the $4.8M crisis grant awarded to the
Department due to COVID-19 by the Substance Abuse and Mental Health Services
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Administration (SAMHSA). This model of peers integrated in crisis response teams will
carry forward as a requirement for all mobile rapid response teams statewide.
4. Contracted with the NH Center for Nonprofits on a series of ten trainings for peer support
agencies to strengthen governance, management, technical and adaptive skills, and
nonprofit best practices.
5. Contracted with the National Alliance on Mental Illness - New Hampshire (NAMI-NH) to
offer peer leadership trainings in SFY 2020 to promote the engagement of individuals with
lived experience across all levels of the mental health system in order to change knowledge,
attitudes and, ultimately, culture regarding the integration and leadership of peers
throughout the State’s mental health system. The first training, a two-day training and
technical assistance workshop, focused on lived experience of people who have
experienced suicidal struggles to help others and prevent future suicidal behavior. The
second, five-day training, promoted leadership and peer support skills for peers working in
traditional care settings as well as in non-traditional peer supported settings. The training
specifically prepared peers to engage with individuals who are experiencing a suicidal
crisis. The next training and technical assistance workshop took place in the fall of 2020.
This workshop series engaged leaders from the Department, peer support agencies, NAMI
NH, community mental health centers, and hospitals.
State Fiscal Year 2021:
1. Contracted with the NH Center for Nonprofits on a series of agency and board of directors
trainings for peer support agencies to strengthen governance, management, technical and
adaptive skills, and nonprofit best practices.
2. Partnered with community providers to expand training and support opportunities for peers
working throughout the mental health system. The Department has begun to host peer
supervisor trainings and has expanded and better publicized annual peer trainings and co-
reflection options to the provider community. The Department has begun gathering
information to build a registry in order to centrally track and maintain contact with all
certified peer support specialists statewide.
3. Expanded training for peers statewide to meet state certification standards including
offering state-funded Wellness Recovery Action Planning trainings. The Department
continues to seek funding to ensure adequate training and professional development
opportunities are available for the peer workforce.
4. Identified two individuals who attended a national Intentional Peer Support (IPS) train-the-
trainer event in SFY 2020. These additional IPS state trainers allowed for greater
flexibility, support for and expansion of the peer workforce. The department has started to
work with IPS Central to identify additional state trainers and offer IPS Core training
virtually in SFY2021.
5. Supported the development of integrated programs such as the Recovery-Oriented Step-
up/Step-down programs that operate as peer run programs with support from the
Community Mental Health Centers for the delivery of clinical services, where appropriate.
6. Developed the Peer Workforce Advancement Plan. Preparation of the Peer Workforce
Advancement Plan included stakeholder input at three (3) public conference/feedback
sessions presented virtually and via written feedback on draft versions. This process was
coordinated by the NH Department and via contract with NAMI-NH and Humannovations.
Participating stakeholders included individuals representing peer support agencies (PSA),
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community mental health centers (CMHCs), community and system advocates, and many
individuals with lived experience. Recommendations of the Advancement Plan focus on
seven (7) “Challenge Areas” for the lived experience workforce, as identified through
research, stakeholder input and key informant interviews: 1. Scope of practice/service
model, 2. Provider culture and workplace readiness, 3. Education and lived experience, 4.
Compensation and advancement, 5. Career entry, transition and attrition. 6.
Placement/reporting/supervision, 7. Service billing and documentation.
To address these Challenge Areas, 13 Recommendations were identified:
1) Peer services orientation for clinical providers;
2) Concise “Fundamentals of Peer Support Training” for all new hires;
3) Peer practices co-learning community;
4) Education, equivalency and training standards;
5) Peer specialist survey;
6) Wage and compensation standards;
7) Peer support employer survey;
8) Lived experience career ladder/tree;
9) Peer support mentorship network;
10) Medicaid billing standards development;
11) Recovery-informed documentation and practices audit;
12) Recovery-focused supervision, performance support, and
accommodation training;
13) Peer Advancement Advisory Council.
Recommendation #8 Establish a Commission to Address Justice Involvement
Governor Sununu’s Executive Order 2019-02 established the Governor’s Advisory
Commission on Mental Illness and the Corrections System to identify solutions and
recommendations for how to reduce incarceration and improve services for such individuals, and
to support individuals with mental illness who are transitioning from jail back to their
communities. Commissioner Helen Hanks at the Department of Corrections serves as Chair of the
Commission. The Commission’s November 2020 report is posted here:
https://www.nh.gov/nhdoc/divisions/commissioner/index.html
Recommendations outlined in the commission report use the 10-year mental health plan as
a framework and call for targeted recommendations to address education, prevention, intervention,
diversion, incarceration, and transition/reintegration. The commission will also examine the
impact of the final recommendations, including financial implications.
The need to expand training opportunities for staff working within the criminal justice
system was an identified objective of the Advisory Commission on Mental Illness and Corrections.
Therefore, the NH Department of Corrections partnered with NAMI NH to offer training sessions
to those who work closely with justice-involved individuals with mental illness to include
administrative, correctional officer and probation and parole staff from the NH Department of
Corrections and community stakeholders to include but not limited to Judicial Branch and law
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enforcement. As of July 2021, 278 individuals have been trained. The trainings offered to date
include:
Building Trauma-Responsive Correctional Setting – 3 trainings, 110 professionals trained
o There is substantial evidence that trauma plays a role in problematic behaviors
exhibited in correctional facilities such as rule violations and violence. To combat
such behaviors, there is a need to adopt “universal precautions” i.e. “trauma-
informed care” when working with justice-involved individuals as the best practice
for those working in the criminal justice system. This training provided attendees
with information to increase understanding of significant prevalence of traumatic
exposure, appreciation of the trauma, psychosocial and system impacts of exposure
to adversity and post-traumatic growth; recognition of the signs of trauma; and
development of approaches and interventions to put knowledge into practice.
Mental Health First Aid/Awareness Training – 27 professionals trained
o Mental Health First Aid is a course that teaches participants how to identify,
understand and respond to signs of mental illnesses and substance use disorders.
The training gives participants the skills they need to reach out and provide initial
help and support to someone who may be developing a mental health or substance
use problem or experiencing a crisis.
Connect Suicide Prevention Gatekeeper Training – 86 professionals trained
o The Connect Suicide Prevention Program (Connect), developed by NAMI NH, is a
national and international suicide prevention program. Connect gatekeeper training
is designed to teach participants about suicide data, identification of risk and
protective factors, and responding to warning signs, intervention strategies, suicide
as a public health issue and its impact on communities, families, and friends,
confidentiality and reporting requirements, best practices around safe messaging,
and self-care skills.
Responding to People with Mental Illness – 29 professionals trained
o In order to safely and effectively resolve situations involving mental illness,
emotional crises, and volatile circumstances, law enforcement and correctional
personnel should understand best approaches, related laws and available resources
that can affect a constructive disposition. This training provides an overview of
mental illness, behaviors and risks, protocols for intervening with a person who is
suicidal, safely de-escalate situations, understand the impact of stigma and trauma,
relevant laws, and understand the impact of trauma on law enforcement and
recognize risk of suicide and resources to reduce risk and promote healthy and
productive management of stress.
Crisis Intervention Team (CIT) Training – 26 professionals trained
o CIT training is comprised of a comprehensive curriculum taught by local specialists
from law enforcement, Emergency Medical Services (EMS), mental health and the
peer/advocate field. CIT highlights best practices, improves community
partnerships and helps communities develop processes to serve people affected by
mental illness with respect and dignity. The 5-day training increases participant’s
knowledge of mental illness, suicide prevention, and signs and symptoms of a crisis
situation and incorporates skills training on engagement and de-escalation.
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The purpose of this initiative was to provide a suite of training sessions to those who work
closely with justice-involved individuals with mental illness to include administrative, correctional
officer and probation and parole staff from the NH Department of Corrections and community
stakeholders to include but not limited to Judicial Branch and law enforcement. Through the
partnership, the offered training sessions provided information to improve outcomes and increase
awareness regarding the complex issues experienced by individuals with mental illness in the
criminal justice system, including:
Lack of appropriate mental health treatment;
Longer jail and prison stays;
Homelessness and lack of affordable housing upon release;
Lack of meaningful employment upon release;
Increased emergency department visits; and
Re-arrest and recidivism.
All trainings were funded by Community Mental Health Block Grant funds that were specifically
designated to support mental health training and technical assistance in NH.
As described above under Recommendation #5 Community Services and Housing
Supports, the Department launched an Integrative Housing Voucher Program, a temporary
supportive housing program that provides a housing voucher coupled with a designated housing
specialist for individuals transitioning out of the New Hampshire prison system or a local New
Hampshire jail. The program supports up to 25 people to create a true network of wrap around
supports with the goal of maintaining mental health and permanent housing.
Recommendation #9 Community Education
The Department will continue to seek opportunities to collaborate with behavioral health
services systems to educate community members about mental illness and wellness and the
importance of considering the social determinants of health as part of the healthcare continuum.
The Department established and launched I Care NH, a mental health and wellness
initiative of the New Hampshire Department of Health and Human Services and the NH Suicide
Prevention Council as described under Recommendation #3.
In accordance with SB 14, the Department is working to establish a statewide family
information and resource center. This information and resource center will provide public
information and education material for parents and caregivers to assist them in access and
navigation of the mental health system. This work is being done in conjunction with the Closed
Loop Referral contract procurement process.
Through a contract with the Department, NAMI NH launched a public awareness campaign
entitled OnwardNH (https://www.onwardnh.org/) to provide information, resource links, and
treatment resources for individuals, families, providers, and educators. There are also videos of
individuals, family members, providers and educators discussing the importance of early
intervention and their experiences. The focus of the campaign is to spread awareness about the
importance of early identification and intervention once the first symptoms of early serious mental
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illness (ESMI), including first episode psychosis (FEP) are recognized. Federal block grant dollars
specifically earmarked for ESMI/FEP funded this campaign.
NAMI NH also led the development of 603 Stories, the anti-stigma campaign to combat
discrimination and stigma around mental health conditions. The 603 Stories website and virtual
collateral was developed and launched in late October 2020. The 603 Stories platform is a curated
gathering of stories shared across mediums – including video, essay, visual arts, and more. A
diverse array of stories were gathered for launch and are continuously updated to remain engaging
and current.
Additionally, NAMI NH has several community education programs including In Our Own
Voice, Life Interrupted, Side by Side and Survivor Voices. NAMI NH, In Our Own Voice is an
educational presentation given by trained individuals with lived experience to educate the public
on recovery from mental illness. Life Interrupted is an educational presentation given by trained
family members of individuals who have a mental illness. Side by Side is an educational workshop
series for caregivers of older adults with a mental illness. Survivor Voices-Sharing the Story of
Suicide Loss is an educational presentation given by a trained speaker who has lost a loved one to
suicide. These programs provide the opportunity for those with lived experience to share their
story, hope and inspiration with the community or other entities that request a speaker. These
programs help to reduce stigma around seeking mental health treatment and support by delivering
messages of hope, resilience and recovery.
Recommendation #10 Prevention & Early Intervention
The Department developed an infant and early childhood mental health plan that identifies
best practices and strategies to enhance and improve services for this young population. Strategies
include training the provider workforce; establishing a billing process that best suits this
population; and focusing on screenings to drive level of care determinations. Other infant and
early childhood mental health strategies include the expansion of early childhood treatment models
and support models, such as home visiting. Funding for the program is contained in HB 1. The
position that will lead this work has been hired and work on implementation of this programming
is now fully underway. Training related to infant mental health was scheduled for May 2020
however, due to COVID-19, this has been rescheduled for fall 2020. The training for providers
will help build the foundation of infant mental health programming. The department anticipates
the remaining activities for implementation will continue from now through winter of 2021 to be
included in rate setting for Medicaid Managed Care in January 2021.
HB 131 established a commission to develop and promote mental health programs and
behavioral health and wellness programs in kindergarten through grade 12. The Commission,
chaired by Representative Patricia Cornell, began meeting in September 2019. The Commission
initially focused on gathering information from different perspectives around the state, including
the Department of Education’s Bureau of Student Wellness, various school districts, the
Department of Health and Human Services, the Manchester Health Department, and the NH Center
for Effective Behavioral Interventions and Supports. This Commission has concluded its work and
published a final report.
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The Department contracted with Dartmouth Mary-Hitchcock (D-H) using designated
federal mental health block grant funds to address early severe mental illness (ESMI) and first
episode psychosis (FEP). Under this contract, D-H has facilitated a stakeholder engagement
process to identify, propose, and develop an implementation strategy for a statewide ESMI or FEP
treatment model. Focus groups, interviews and steering committee work informed the resulting
model and current implementation efforts. HB 1 included funds to support the implementation of
the selected ESMI/FEP model and funds are available through several federal block grants.
NH has had one ESMI/FEP treatment team at Greater Nashua Mental Health (GNMH), the
HOPE (Helping Overcome Psychosis Early) team. In July of 2021 three additional Community
Mental Health Centers contracted to begin the work to stand up an evidence-based ESMI/FEP
program. These CMHCs are within the Monadnock Region, Seacoast Region, and Southern NH
region. The Department is utilizing SAMHSA block grant funds to support the training in the
evidence-based NAVIGATE model for all three teams and initial staffing of the new ESMI/FEP
programs. Quarterly meetings with all four centers will occur to support a learning collaborative
and supportive environment to those with ESMI/FEP focused programs. At this time the state is
also leading efforts to establish a center for excellence to support training needs of all ten
community mental health centers to support the availability of ESMI/FEP services statewide. To
support implementation, the department posted a Request for Proposals (RFP) to solicit proposals
for the provision of statewide training for evidence-based practices (EBP) and the implementation
of a Center of Excellence for a Coordinated Specialty Care (CSC) model for the treatment of
ESMI/FEP.
The expectation is to implement a Statewide Center of Excellence to bridge gaps between
research, policies and practices for an evidence-based Coordinated Specialty Care (CSC) model
for the treatment of First Episode Psychosis (FEP) through a collaborative and supportive effort
with the Community Mental Health Centers (CMHCs) within New Hampshire. The Center of
Excellence shall provide services to include, but are not limited to training; consultation services;
technical assistance; and program fidelity reviews. The contract is in process and with anticipated
approval in the fall of 2021.
The Bureau for Children’s Behavioral Health has finalized a plan for Early Childhood
Prevention and Treatment for Behavioral Health. This programming seeks to intervene early on
with young children who are showing signs of concern or are considered at risk for behavioral
health concerns later in childhood. The program consists of assessment, treatment with child and
parent, enhanced care coordination and home based services and supports. The Bureau is currently
seeking appropriate funds to implement this programming.
Recommendation #11 Workforce Coordination
The pandemic has added strain to the existent mental health workforce shortages. In
December of 2020, New Hampshire’s community mental health centers reported an average
vacancy rate of 8.4% across all Centers with 220 total vacancies throughout the system. As New
Hampshire looks to expand programming to meet the increasing mental health needs of its citizens,
intentional focus must be given to workforce development, recruitment, and retention.
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Governor Sununu’s Executive Order 2019-03 established the Statewide Oversight
Commission on Mental Health Workforce Development. The Commission shall serve as a
statewide coordinator for all efforts to address NH’s mental health workforce shortage and shall
develop strategies to boost recruitment and retention of a mental health workforce for the state.
The committee was established and began meeting in August 2019. Will Arvelo, Director of
Economic Development, Department of Business and Economic Affairs serves as Chair of the
Commission. The Commission filed a report in November 2019 that summarizes the
Commission’s activities and recommendations.
The commission continues to meet to address topics such as workforce development and
training, workforce challenges and gaps, health of the workforce, student loan repayment,
legislative and policy considerations, and licensing standards. Some workforce initiatives include:
Evidence Based Practices Training and Technical Assistance: Through contract with Dartmouth
Mary Hitchcock (D-H), staff training and programmatic consultative services are provided to
support implementation of evidence-based programs including Assertive Community Treatment
(ACT), Individual Placement and Support – Supported Employment (IPS-SE) and Illness
Management and Recovery (IMR). Annual trainings are provided to ensure staff obtain the
necessary credentials to provide services within these evidence-based programs. D-H consultants
also provide consultative services to agencies to support their development of quality service plans
targeted to improve implementation of high-fidelity programs.
Crisis Workforce Enhancements: In order to ensure that specialty-trained crisis teams are
adequately staffed, the Covid-19 Supplemental Funding for the 5% Crisis Services set-aside funds
will be directed to support workforce development and expansion. All staff, regardless of
credentials, will be required to complete a comprehensive crisis training modeled on the National
Guidelines for Crisis Care: Best Practice Toolkit, prior to deployment. The required training will
be a minimum of 40-hours and include topics such as crisis intervention and de-escalation
techniques, addressing recovery needs, risk assessments, legal considerations, cultural
competence, and community resources. Undertaking a massive training initiative like this will
require providers to remove staff from clinical practice to attend training. This will create a
workforce and financial burden on providers. Therefore, funds will be used to support training and
back-fill expenses. Providers will receive a $1,000 stipend for each staff who completes the
required crisis training and goes on to work on the Rapid Response crisis team. Up to 150 stipends
will be issued statewide. These stipends are specifically targeted to agencies providing staff and
staff time to engage in this training. These stipends will not be used to pay for the trainee’s time
or services.
Cross Department Training for Criminal Justice Staff: As referenced above under recommendation
# 8, in 2021, the Department allocated mental health block grant TA funding to the Department of
Corrections for a series of training sessions for people working with individuals with mental illness
involved with the justice system. Attendees include employees of the Department of Corrections,
the New Hampshire court system, and law enforcement organizations statewide. Trainings include
Building Trauma-Responsive Correctional Settings; Mental Health First Aid/Awareness Training;
Suicide Prevention Training; Responding to People with Mental Illness; and Crisis Intervention
Team Training. Trainings directly address recommendations within New Hampshire's 10-year
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mental health plan. Based on Recommendation #8 in the 10-year mental health plan, the
Governor's Executive Order 2019-02 established an advisory commission on mental Illness and
corrections to make recommendations on steps that can be taken to reduce incarceration and
improve mental health services. As of July 2021, 278 individuals have been trained.
Additional Accomplishments: HB 1 included funds to expand NH’s State loan repayment
program, which includes opportunities for individuals working in the behavioral health system to
apply for loan repayment.
The Department, as referenced above under recommendation # 7, Integration of Peers and
Natural Supports, created a stakeholder-informed Peer Workforce Advancement Plan. The
workforce advancement plan will serve as a roadmap to expand employment and training
opportunities for individuals with lived experience. There is a significant need to expand the peer
workforce given the system transformation taking place with mental health housing and crisis
services.
As described above under recommendation #10 Prevention and Early Intervention, the
Department is utilizing SAMHSA block grant funds to support workforce training for the three
implementing new ESMI/FEP programs. At this time the state is also leading efforts to establish a
center for excellence to support training and technical assistance needs of all ten community mental
health centers to support the availability of ESMI/FEP services statewide.
Recommendation # 12 Quality Improvement and Monitoring/DHHS Capacity
HB 1 included funding for one additional staff position within the Bureau of Mental Health
Services to assist with the oversight of quality, implementation, monitoring, and reporting of the
10-year mental health plan. The position was created and posted but was on hold due to the
statewide hiring freeze during the COVID-19 state of emergency and is currently unfunded.
SB 14 includes additional staff positions to support the implementation and oversight of
investments to the children’s behavioral health system. Four of the five positions called for in SB
14 have been filled. With the hiring of these new staff, as of July 2021, the Bureau for Children’s
Behavioral Health has expanded from a staff of five to now nine staff. One position remaining to
be hired is now on hold due to the statewide hiring freeze. The five new staff positions will
support:
One Infant and Early Childhood Mental Health programming position (filled)
Two Residential treatment staff to support, operations, oversight, quality assurance
and program development (filled)
One FAST Forward Program Eligibility and CME oversight position (filled)
One Mobile Crisis and Community Based programming position (filled as of
8/13/21)
Hiring additional staff has been a critical step to having the necessary program capacity to
support implementation of the 10-year mental health plan.
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Recommendation #13 Streamlining Administrative Requirements
Governor Sununu’s Executive Order 2019-04 established a DHHS Division of
Performance Evaluation and Innovation, which has been formally named the Bureau of Program
Quality and Integrity (BPQI). This bureau’s focus is to improve transparency, streamline
operations, and review administrative and reporting requirements on behalf of the
Department. Over the last year, BPQI has supported program areas to oversee contracted vendors
and has provided technical assistance to improve quality metrics for bureaus within the Division
for Behavioral Health.
Per Executive Order 2019-04, the Division for Behavioral Health conducted an inventory
of all of the requirements for community mental health providers. The inventory includes the
number of touch points the Department has with providers, creating a crosswalk of quality service
reviews, fidelity reviews, designations and re-designations, Community Mental Health
Agreement-related activities, all of these touch points require critical provider staff time that is not
directly spent meeting the needs of individuals with severe mental illness. The inventory also
includes a review of state statute and administrative rules.
The Department continues to leverage opportunities to streamline administrative
requirements. Some examples include:
Quality Service Reviews: The Department conducts annual Quality Service Reviews (QSR) of the
Community Mental Health Centers (CMHCs). Efforts to streamline the QSR process have
included examining workflows and processes. Improvements were made such as eliminating
manual data entry into redundant forms, creating a central data repository to increase
efficiency, creating a “No Evidence” form for use in chart audits, utilizing Department generated
data reports, and standardizing the five-day review process for client record reviews and client and
staff interviews. These improvements better organize the process and reduce unnecessary and
overwhelming back and forth communication. Developing options to review case files remotely
and conduct staff and service recipient interviews virtually also created efficiencies; the review
team now spends 40% less time at the center, eliminating the need to allocate space at the
CMHC and saves travel time and expense for Department staff. Additionally, some service
recipients preferred to interview via a virtual option and this increased the availability of
individuals to interview and provide feedback as part of the QSR process.
Data Improvement Efforts: The Department is utilizing Department gathered data to support
system oversite and quality reviews. Through ongoing quality improvement efforts with the
CMHCs, encounter data submitted to the department is improving in terms of data integrity,
accuracy, and reliability. This enables the Department to generate data reports to inform program
quality and system improvement efforts. For the second year in a row, the Department provided
$30,000 to each CMHC through contract in SFY 2021 to implement data improvements. Data
improvements to date include:
All clinical providers contracted with the Department for the delivery of mental health
treatment services will report through a central data base platform, Phoenix. This
eliminates the need to create, upload, and submit separate data spreadsheets.
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The Department identified areas within the Phoenix system that required system wide
changes to improve data integrity and quality reporting.
o The fall 2019 updates included the development of a single, standard format for
Designated Receiving Facilities (DRF) data submission, mobile crisis response
data book that outlines standard definitions and data submission practices, and a
coding matrix that will self-populate ACT staffing reports.
o The fall 2020 updates included the expansion of client level data to extract race,
ethnicity, language and sexual orientation and identity data as well as housing and
tobacco use data. These data enhancements will streamline the Department’s ability
to submit SAMHSA’s federal data reporting requirements and enable more
accurate analysis, trend projections, and dashboards.
The Department has developed internal mental health data dashboards to track system
utilization and service delivery. These data dashboards will also drive program and quality
efforts with providers.
Fidelity Reviews: Beginning March 2020, all Assertive Community Treatment (ACT) and
Supported Employment (SE) fidelity reviews were cancelled due to the public health emergency
declared due to COVID-19. In collaboration with the Department, and in consultation
with national experts of ACT and SE, in lieu of conducting fidelity reviews, Dartmouth Mary-
Hitchcock (D-H) consultants converted scheduled fidelity reviews to in-depth consultations. These
consultations assessed the core elements of the fidelity of each practice, as well as specific quality
indicators to assess strengths and areas of challenge during the pandemic. These consultations did
not include scoring because practices required adaptations due to safety concerns and safety
mandates that scoring requirements do not accommodate. However, following each consult, the
D-H consultants provided each team with a detailed consultation report that addressed
observations, feedback, strengths and recommendations. Work has recently begun to streamline
the quality improvement plans, identifying areas for automatic input of information, combining
action steps that could address multiple areas of need, and increased technical assistance to ensure
quality improvement plans are robust and targeted to effect the intended change.
State Administrative Rules: The Department was in the process of updating several administrative
rules attendant to mental health services but these efforts paused as a result of the COVID-19
pandemic. Mental Health rules are again under review and stakeholders will engage in the review
process starting in fall 2021.
The Department reviewed the re-approval process as defined in He-M 403.11 that takes
place every 5 years to maintain certification as a community mental health program
(CMHP) to identify administrative efficiencies; cross-walked re-approval requirements
with annual Quality Service Review (QSR) reporting, Managed Care Organization (MCO)
reporting and Consumer Satisfaction Survey results in an effort to further streamline the
re-approval review process;
During the summer of 2021 the Designated Receiving Facility rule, He-
M 405, was reviewed and an emergency rule was implemented in response to Executive
Order 2021-09 wherein the Governor called for actions to address the mental health crisis
in the State of NH. Following the emergency rule, informal stakeholder engagement
commenced in preparation for the formal rule making process. Changes to the rule include
clarifying reporting, care collaboration, and admission requirements.
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Additional Accomplishments: The Department worked with all three MCOs to utilize a
single, standard audit tool and to conduct reviews of the community mental health centers (CMHC)
on a rotating basis to ensure that only one MCO conducts an audit in any given month; and worked
with the MCOs and CMHCs to adopt the use of a standard sentinel event reporting form.
The Department has been working to achieve relief for certified community residences to
meet the requirements of He-M 1202 - Administration of Medication. In order to ensure that staff
had the required training during the COVID-19 pandemic, the Department enlisted a vendor to
establish an on-line training platform to satisfy the He-M 1202 annual training requirements for
currently trained providers. He-M 1202 requires annual certification for all staff working in
certified community residence in order to ensure the safety of residents and oversight of
medication monitoring practices. The new virtual training enabled staff to retain certification and
will continue to do so moving forward. Accommodations were also developed to enable
medication monitoring via secure video-conferencing (telehealth) which has greatly assisted in
instances where staff shortages were of concern.
Recommendation #14 Reporting on Implementation
SB 292, relative to implementation of the new 10-year mental health plan, requires the
DHHS commissioner to submit a report containing the priorities for implementation of New
Hampshire’s 10-year mental health plan on an annual basis. Reports are to include the status of
implementation, unmet benchmarks, recommendations for any necessary barrier resolution,
adjustments, or modifications needed to the plan, and any recommendations for legislation needed
to fully implement the 10-year mental health plan. The Department will include this information
in its annual report.
Reports submitted October 2019, December 2019, September 2020, September 2021.
Future Plans
Moving forward, we will continue to work in partnership with stakeholders, individuals
with lived experience and their families and providers to implement strategies, programs, and rules
that will strengthen and improve our mental health system to better serve New Hampshire citizens.
We expect there will be an increased demand for mental health services in the coming months due
to the COVID-19 pandemic and the Department is moving the efforts described in this report
forward as quickly as possible. The goals of the 10-year mental health plan can only be realized if
fully supported and fully funded. Review and adaptation of the 10-year mental health plan to
changing conditions in concert with the biennial budget cycle is critical to successful
implementation. The Department is committed to the 10-year mental health plan but cannot carry
the plan forward alone. As stakeholders asserted, actualizing the plan will rely on leadership, active
collaboration, and ongoing support. The Governor and Legislature must champion the plan and
continue funding the next phase of implementation. The Department will continue to work with
stakeholders to identify legislation and funding needed to meet our shared goal of full
implementation.
